Out-of-pocket (OOP) expenditures for childbirth in Bangladesh have increased substantially, intensifying financial pressure on lower-income households. While wealthier groups historically bore higher delivery costs, recent trends indicate a narrowing gap in spending across socioeconomic strata. This study investigates the drivers of this convergence in delivery-related expenditures between 2014 and 2022, distinguishing between demographic shifts and changes in medical service utilization. We analyzed nationally representative data from the 2014 and 2022 Bangladesh Demographic and Health Surveys using a retrospective two-stage stratified sampling design. Inequality in expenditures was assessed using the concentration index, and decomposition analysis was applied to quantify the contribution of explanatory factors. Between 2014 and 2022, the concentration index for delivery expenditures declined from 0.37 to 0.20 (Δ = −0.17, p 0.01), reflecting a significant reduction in wealth-related inequality. During this period, the average cost of delivery rose from 9,486 to 13,217 BDT, and the cesarean section (CS) rate nearly doubled from 24 to 46%. Decomposition analysis revealed that the decline in inequality was driven almost entirely by increased CS and institutional deliveries among poorer households. CS alone accounted for 69% of the reduction in the concentration index, primarily due to increased uptake among less affluent groups. Normal institutional deliveries explained most of the remaining change, while maternal risk factors, antenatal care, and sociodemographic variables had minimal influence. These findings show that delivery expenditures have become more evenly distributed across wealth groups, driven primarily by changes in delivery mode rather than shifts in health or demographic risk. However, the sharp rise in cesarean sections as the major contributing factor and especially among poorer households—well above international recommendations—points to potential over-medicalization and increased financial vulnerability, with implications for health equity and system sustainability. In the absence of universal health coverage and given substantial out-of-pocket payments, greater spending equity may signal worsening financial protection, even as access and utilization become more equitable.
Fischer et al. (Wed,) studied this question.